Failure to Diagnosis Lithium Overdose Claim in Baltimore

Westreich v. St. Agnes Healthcare, Inc.

This is a failure to diagnose medical malpractice lawsuit filed by a man in Health Claims Arbitration on March 6, 2017. He alleges that the doctors at Patient First and St. Agnes Healthcare in Baltimore City failed to diagnose his lithium toxicity and as a result he is left permanently disabled. It is the 111th medical malpractice case filed in Maryland this year.

Summary of Plaintiff's Allegations

Plaintiff, a 22-year-old man previously diagnosed with autism and bipolar disorder, goes to Patient First with diarrhea. He also indicates that he feels weak and shaky. He states that he is on Lithium (used to treat bipolar disorder) and Olanzapine (an antipsychotic) for the past year. Despite this, his lithium level is not checked. He is diagnosed with gastroenteritis and given a prescription for double strength Bactrim (an antibiotic).

The next morning, plaintiff takes his normal dose of Lithium. However, in the afternoon, his symptoms become much worse and he goes to St. Agnes Hospital Emergency Room with an altered medical status, diarrhea, shaking, drooling, and weakness. His medical diagnosis includes medication non-compliance, electrolyte abnormality, dehydration, and infection. Once again, his lithium level is not checked.

When taking lithium, the level of lithium in one's blood is monitored to avoid lithium toxicity, which is a medical emergency. Common symptoms of early lithium toxicity include lethargy, weakness, shakiness, and diarrhea, which can lead to dehydration and a compromised renal function. If it becomes severe, lithium toxicity can lead to an altered medical status and confusion.

Plaintiff is admitted to the neuro department at St. Agnes that evening. A lithium level test is ordered but is not completed. The following day, the test is ordered again, and the results indicate a "very dangerous" level. An emergency dialysis catheter is placed and after four homes of hemodialysis, the man's lithium level lowered into an acceptable range.

For the next few days, plaintiff's altered mental status and fevers persist. He develops a stiff neck. Despite this, he is re-prescribed Olanzapine, the antipsychotic. The following day, he is diagnosed with neuroleptic malignant syndrome and prescribed Dantrolene (a muscle relaxant) to be administered intravenously. The plaintiff's temperature and stiffness improved with this, however his altered medical status does not. The defendants indicate that his change in mental status is not likely to return to baseline.

Plaintiff alleges that the defendant's failure to timely check his lithium level and to properly treat him led to him becoming permanently disabled and requiring 24 hour care.

Additional Comments

The critical issue in the case is if the one or two day delay in diagnosing this lithium cause this man injury and, if so, what was the injury.

Lithium toxicity can present with tremors, agitation, confusion, and tremors. It can also cause nausea, vomiting, and, importantly in this case, diarrhea. The question be whether this symptom combined with the arguably neurological symptoms of being "weak and shaky" should have led a reasonable, prudent doctor to rule out Lithium intoxication.

The other big question is damages. Did the delay in diagnosis make a difference for this patient? One doctor says the patient did not return to baseline. How serious of an injury is this? Does he require more ongoing care as a result? These will be big issues in this case.

Kenneth C. Fischer, M.D. - associated with North Shore Medical Center and University of Miami Hospital; specializes in neurology

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